CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Appropriate Use Criteria: Imaging of the Abdomen and Pelvis EFFECTIVE MARCH 9, 2019 Proprietary 8600 West Bryn Mawr Avenue Appropriate.Safe.Affordable South Tower – Suite 800 Chicago, IL 60631 © 2017 ©©©© 2019 AIM Specialty Health® www.aimspecialtyhealth.com 2057-0319 Imaging of the Abdomen and Pelvis Table of Contents Description and Application of the Guidelines .......................................................................................................... 5 General Clinical Guideline ........................................................................................................................................... 6 Clinical Appropriateness Framework .................................................................................................................... 6 Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions .................................................... 6 Repeat Diagnostic Intervention .............................................................................................................................. 6 Repeat Therapeutic Intervention ............................................................................................................................ 7 History ...................................................................................................................................................................... 7 Imaging of the Abdomen and Pelvis .......................................................................................................................... 8 General Information/Overview ................................................................................................................................ 8 Scope .................................................................................................................................................................... 8 Technology Considerations ................................................................................................................................... 8 Definitions .............................................................................................................................................................. 9 Clinical Indications .................................................................................................................................................... 11 General Abdominal and Pelvic Indications ......................................................................................................... 11 Congenital and developmental conditions ........................................................................................................... 11 Infectious and inflammatory conditions – not otherwise referenced .................................................................... 11 Trauma ................................................................................................................................................................ 12 Tumor or neoplasm – not otherwise referenced .................................................................................................. 12 Female Reproductive System and Obstetrics ..................................................................................................... 12 Adenomyosis ....................................................................................................................................................... 12 Adnexal mass ...................................................................................................................................................... 12 Endometriosis ...................................................................................................................................................... 13 Obstetric indications ............................................................................................................................................ 13 Uterine artery embolization procedures ............................................................................................................... 13 Gastrointestinal Conditions .................................................................................................................................. 14 Appendicitis ......................................................................................................................................................... 14 Bowel obstruction ................................................................................................................................................ 14 Constipation (Pediatric only) ................................................................................................................................ 15 Diverticulitis ......................................................................................................................................................... 15 Enteritis and colitis .............................................................................................................................................. 15 Foreign body (Pediatric only) ............................................................................................................................... 16 Gastrointestinal bleeding (Pediatric only) ............................................................................................................ 16 Henoch-Schonlein purpura (Pediatric only) ......................................................................................................... 16 Inflammatory bowel disease ................................................................................................................................ 16 Intussusception (Pediatric only) ........................................................................................................................... 16 Ischemic bowel .................................................................................................................................................... 17 Hepatobiliary Conditions ...................................................................................................................................... 17 Ascites ................................................................................................................................................................. 17 Biliary tract dilatation or obstruction ..................................................................................................................... 17 Cholecystitis ........................................................................................................................................................ 17 Copyright © 2019. 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All Rights Reserved. 2 Imaging of the Abdomen and Pelvis Choledocholithiasis ............................................................................................................................................. 18 Diffuse liver disease ............................................................................................................................................ 18 Focal liver lesion .................................................................................................................................................. 19 Hepatomegaly ..................................................................................................................................................... 20 Jaundice .............................................................................................................................................................. 20 Primary sclerosing cholangitis ............................................................................................................................. 21 Osseous Conditions .............................................................................................................................................. 21 Avascular necrosis .............................................................................................................................................. 21 Axial spondyloarthropathy ................................................................................................................................... 21 Developmental hip dysplasia (Pediatric only) ...................................................................................................... 22 Osseous tumor .................................................................................................................................................... 22 Osteoid osteoma ................................................................................................................................................. 23 Osteomyelitis ....................................................................................................................................................... 23 Pelvic fracture ...................................................................................................................................................... 23 Sacroiliitis ............................................................................................................................................................ 24 Septic arthritis ...................................................................................................................................................... 24 Pancreatic Indications ..........................................................................................................................................